The Indian government used the pandemic to craft a political image and failed to save lives

Why did most Indians find themselves alone and without state support while facing illness, death, loss of livelihood, displacement and poverty during the COVID-19 pandemic? It is because the Indian government’s response at every stage was primed by a “compulsive need to maintain a positive political image,” argue journalist Vidya Krishnan and public health specialist Sarah Nabia, in a forthcoming anthology A View From The Margins. The anthology has writings by forty authors who have documented the first year of the pandemic in India. The book will be published by Manohar Booksin November 2021.

In the following excerpt from a chapter in the anthology, Krishnan and Nabia trace the Indian government’s decisions, from March 2020 to the second half of 2021, to find that politics eclipsed evidence-based policy in its actions.  

On 3 February 2020 a weekly report from National Centre for Disease Control recorded three positive cases of COVID-19 in India, all from Kerala, one of the few states diligently screening people at airports. The NCDC, an agency with most expertise to track the virus, would not publish a single report for the rest of 2020. As of August 2021, around four million Indians may have died from coronavirus, according to a study released by Centre for Global Development, while official figures have under-reported deaths by at least a factor of ten and the government celebrates its “successful handling” of the first wave of the pandemic in the report Chasing the Virus: A Public Health Response to the COVID-19 Pandemic In India. The central government took on the difficult task of organising a pandemic response in a developing country like India—where even in non-emergency times the health system lacks the capacity to cater to populations in rural and conflicted areas—and made it harder still. 

The only way to mount an effective response was through meticulous planning, coordination, and cooperation between the scientific and political leadership—all areas in which we have badly faltered. This chapter documents the interplay between the political and scientific leadership in the country and its consequence on people’s lives. 

As the pandemic made its way through India, people turned to newspapers and prime-time talk shows to learn about the scale of threat and for guidance on how to weather this once-in-a-century health disaster. While the virus spread through India, we saw scientific discussion being led by political leaders while scientists stayed in the background. The take-over of scientific communication was evident from the early days when the health ministry became the epicentre of the COVID-19 response and NCDC, a public health agency set up for communicable disease surveillance and control, was nowhere to provide briefings or guidance. Four months into the pandemic and 1.2 million confirmed cases later, the government continued denying “community transmission” of the virus in India, an instance of political interference in the scientific determination of the stages of disease transmission, all in a compulsive need to maintain a positive political image. In November 2020, for the first time in independent India’s history, a major political party used the promise of “free vaccines” to woo voters ahead of one state’s elections at a time when not a single vaccine for COVID-19 had been approved. The announcement placed unreasonable pressure on scientific bodies to produce results in impractical timelines, raising safety concerns and doubts whether the required scientific processes have been adequately followed. This pressure was evident on the Indian Council of Medical Research to launch a vaccine by 15 August 2020 in a leaked letter that was widely circulated. At this point, Pfizer, Moderna and Astra Zeneca vaccines were still in phase III clinical trial. Covaxin, India’s indigenous vaccine candidate by Bharat BioTech, was not yet in the phase III trials to assess the vaccine’s efficacy.

One of the highlights of India’s COVID-19 response was the nation-wide lockdown, precursor to the largest intra-country migration since the partition of India, displacing millions of people. Even though “movement restriction” is a widely used infectious disease control strategy, an ill-planned implementation created an economic as well as humanitarian crisis in addition to the medical emergency. The lockdown, following months of denial of community transmission and rumours about the coronavirus not surviving Indian summer, was imposed without consulting the nation’s top scientists in the national task force, a group of experts constituted to provide scientific direction to COVID-19 strategy. Even though the impact of the lockdown on disease transmission is still unknown, the hastily scientific decisions by political leaders showcase how little autonomy institutions had.

Through the first wave, the country’s highest leadership consistently denied the scale of India’s public health crisis with a mix of misdirection and unscientific strategies. Right from the start, remedies such as in homeopathy and Ayurveda for COVID-19 prevention or treatment, without any proven efficacy, were backed by the Ministry of AYUSH. These remedies offered legitimate recognition in the government’s treatment protocol, once again clouding science with politics. ICMR, the go-to place on treatment policy for doctors in India, failed to update the treatment protocol for COVID-19 to align with global standards as well as its own findings. Seven months after ICMR published evidence that showed convalescent plasma to be ineffective in COVID-19 treatment, it had not removed it from the treatment protocol. Meanwhile, the chief minister of a north-Indian state delivered public statements on the benefits and use of plasma therapy, reassuring people of the effects of a scientifically unproven therapy, at a time when prices for plasma soared in the black market. 

Similarly, injudicious prescription of Remdesivir continued and prices soared in the black market with reports of a Rs 5,500 vial selling for anything between Rs 15,000 to Rs 60,000, despite evidence from WHO’s large multi-country trial that Remdesivir has little to no effect on hospitalised patients. The sheer negligence to update policy made the ground fertile for the black market that emerged, resulting in sub-optimal treatment for millions across India.    

In April 2021, as India was in the grip of a deadly second wave, five scientists told Reuters that they had warned Indian officials in early March of a new and more contagious variant, only to be ignored by the government. Despite early warnings, the centre did not seek to impose restrictions, in contrast to its hard-line lockdown during the first wave. Instead, millions of largely unmasked people attended religious festivals and political rallies. Through this period, India’s top scientists helplessly watched as daily cases went up from 12,772 on 1 February to 391,008 on 9 May. By now the lack of a coordinated effort between the government and scientific agencies to prioritise political gain over public health was unignorable, and the medical horror that followed during the second wave was inevitable.

The vaccine policy was guided by priorities of foreign diplomacy, appeasement of the corporate sector, and a push for “self-reliance” bordering on jingoism over scientific and operational pragmatism. Miscalculations with the vaccine policy was the fatal flaw from which all other misfortunes would follow, including a global shortage of COVID-19 vaccines due to shortages resulting from India. India was the first country in the world to place the vaccine in the hands of the private sector, at terms favourable to the industry. 

Within the first week of vaccine roll-out, Deepak Marawi, a 45-year-old father of three from Bhopal, would die after receiving the vaccine, stoking vaccine hesitancy in a country already struggling with crumbling health infrastructure. India inoculated 200,000 people on the first day of the vaccination drive —the highest first-day total for any country but the lack of forecasting demand, unjustified price of vaccines, and unfair policies resulted in less than 10 percent of the population being fully vaccinated as of August 2021.

The Central Drugs Standard Control Organisation’s policy, like NCDC, was more aligned with the political priorities and less with scientific rationalism. In December 2020, USFDA approved Pfizer/Moderna’s mRNA-based COVID-19 vaccine for emergency use. A month later, on 2 January 2021, the CDSCO approved Bharat BioTech’s Covaxin for restricted use in clinical trial mode, when the phase III clinical trial to assess the vaccine’s efficacy was still recruiting participants. After giving Bharat BioTech a rushed approval, there is little justification to why the same sense of urgency did not apply to Pfizer’s initial application. After filing in February 2021, Pfizer withdrew its application citing lack of local bridge-trials to prove vaccine’s safety and efficacy. Hidden in the garb of safety-concerns, CDSCO’s decision was motivated by an ambitious attempt to push the domestically developed Covaxin (which still does not have efficacy data in the public domain as of 30 June 2021) while de-prioritising other vaccine candidates which had concrete efficacy data, and were being used globally. 

The lack of vaccines in the market was compounded by the decision to use vaccines as a tool for soft-diplomacy, while horribly miscalculating domestic needs. India’s vaccine policy not only caused distress and suffering in India but also in nearly hundred low and middle income countries that relied on it for vaccine supplies. At this point, rich Indians were wading through a maze of OTPs and mobile apps to pay for vaccines, while bodies were floating in the Ganga because poor families across rural India did not have money to perform final rites for their loved ones with dignity. The focus on online registrations ignored the fundamental fact that more than half of the Indian population doesn’t have access to the internet, computers or smartphones. The pervasive grief felt by Indian citizens during the second wave, as they dealt with a once-in-a-century pandemic, was only matched by the knowledge that they were on their own.

By now, health experts were clear that the only way to fill in the huge deficit in India’s vaccine supply was to turn to Chinese-made vaccines, which had the added advantage of not requiring extensive cold-storage facilities. Despite being warned about the mutant strain and the oncoming tsunami of infections, there was reluctance to initiate a vaccine import deal with the Chinese government, probably due to recent political disputes between India and China. However, this provides little rationality as India imports nearly 68 percent of its bulk drugs and drug intermediaries from China.

To vaccinate everyone above 18 years of age by the end of 2021, India would need to administer 7.5 million doses per day. By May, India, a global pharmaceutical powerhouse with proven capacity to meet high production volumes, was vaccinating 2.3 million people per day—less than what India has donated to the world.

If the rationale behind COVID-19 vaccine approvals made no sense, the vaccine pricing strategy ensured that the precious few doses were more easily available to the rich people. In March 2021, the central government announced that it would procure 50 percent of vaccine stocks from Serum Institute of India and Bharat BioTech at the negotiated price of Rs 150 per dose. Of the rest 50 percent stock , 25 percent was earmarked for the state governments and the last 25 percent for private sector providers with no regulation on prices. This strategy set the stage for the organised loot that followed. The SII was selling the same vaccine to state governments at Rs 400 and Bharat BioTech decided to charge Rs 600 to state governments, and charged a further inflated price of Rs 1,200 from private hospitals, who then added their own charges before it was administered to the citizens. It is unexplainable why the central government would forgo its ability to negotiate a bulk price, and instead allow profiteering in the middle of a pandemic. It is also not clear why the central government did not cap the prices, when it relaxed the vaccine policy in favour of pharmaceutical companies.

Dr KV Balasubramaniam, a vaccine industry expert, estimated the cost price of Covaxin to be around Rs 40 and that of Covishield would be Rs 25-30. At a cost of Rs 150, the pharmaceutical manufacturers would still have a 375 percent mark-up on the cost prices, and much lower than the current prices being charged by SII and Bharat BioTech in the open market. There is little defence for not implementing an efficient price-control measure given India’s experience implementing a pricing cap on cardiac stents. In a landmark decision in 2017, the National Pharmaceutical Pricing Authority capped stent price at Rs 29,000, resulting in almost 85 percent price reduction in the markets. It is unfortunate that the successful price-control policy measures were not transferred to COVID-19.

The pricing strategy was economically as well as morally repugnant. The Indian taxpayer had funded the vaccine for which ICMR is entitled to five percent royalty from the sales of Covaxin. It ended up becoming the world’s most expensive vaccine to which the majority of Indians did not have access.

India, which takes pride in being the pharmacy of the world, has been a critical supplier in the global effort to vaccinate people against vaccine preventable diseases. By 2021, over 70 nations had received vaccines made in India, with a total of more than 60 million doses.

The miscalculations made in India had a ripple effect across low and middle income countries dependent on supplies from here. The surge of deaths in India had a domino effect on vaccination drives in many other countries. Nepal, one of Asia’s poorest nations, and heavily dependent on vaccine supplies from India, halted its vaccination campaign in March. Forty African countries depended on the COVAX facility and the SII for their quota of COVID-19 vaccine supply. The sudden embargo on vaccine export left millions in a limbo as nearly 80 percent of the initial vaccine stocks have been administered as a first dose in India, with little certainty over when they could get the second dose. The government then suspended exports of nearly all 2.4 million doses of the AstraZeneca vaccine produced at SII so it could be used in India instead.

Going into the pandemic, India’s robust vaccine industry was the strongest weapon in the government’s arsenal. Since independence, India has annually run the world’s largest immunisation program, delivering vaccinations to 55 million people a year. Never once had Indian states competed against each other for supplies. 

All of this government bungling and the disjointed messages between government and scientific institutions can be a potential driver of vaccine hesitancy among Indians. Recent surveys among medical students have shown that one out of 10 students are hesitant to take the COVID-19 vaccine, and the rate of hesitancy among the general population is estimated to be a significant 25.5 percent while some high-literacy states such as Tamil Nadu are reporting 42 percent hesitancy.

Any analysis of state’s pandemic response is a count of errors piled on errors. After ignoring warnings from scientists, promoting unproven homeopathic and ayurvedic interventions of COVID19, crippling the vaccine supply, allowing mass gatherings for political rallies and religious festivals, and declaring a false “victory” over the pandemic before the second wave, the state actively pitted states against each other for vaccine supplies—another first in India’s history.      

The gaps in communication between government and scientific agencies, on public display during a pandemic, has compounded the chaos that surrounds the vaccine policy to this day. Facing shortages and criticism, the government compounded the chaos by increasing the dosing gap for the SII-made Covishield from 12 weeks to 16 weeks [from four to eight weeks earlier]. Once again, scientists told the media they were not consulted on the decision. The constant bungling has irreparably eroded the trust citizens have in government and scientific institutions, creating a previously unheard levels of vaccine hesitancy among Indians. The centre’s apparent disregard for the opinion of the country’s top scientists is in keeping with its conduct from the beginning of the pandemic.

The constant display of science denialism has contributed to vaccine distrust even among students of medicine and future health care providers, a reflection of the larger society. The damage to vaccine confidence will cast a long shadow over India, much after the COVID-19 pandemic is over. India takes pride in its vaccine successes—polio elimination being its biggest and only victory in public health since Independence—but the vaccine hesitancy generated as a consequence of political agenda trying to drive the scientific process may have set us back in the fight against vaccine preventable diseases by many years.

Lives of India’s most vulnerable citizens were upended as a result of coordinated failure to privilege science over politics. India’s Scientific and research organizations, NCDC, ICMR, CDSCO, and the health ministry, actively led us down this path we find ourselves in today, with four million already dead, and the pandemic nowhere near over.